Diagnostic value and complications of fine needle aspiration for primary liver cancer and its influence on the treatment outcome—A study based on 3011 patients in China

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Abstract

Aim

To determine the diagnostic value and major complications of fine-needle aspiration (FNA) for primary liver cancer (PLC) and its influence on the treatment outcome and prognosis.

Methods

Information was gathered retrospectively for 3011 patients who presented with suspected PLC. Of which 2528 cases underwent ultrasound-guided fine-needle aspiration (US-FNA) biopsy. Patients were followed up through repeated office visits and imaging studies with a median follow-up of 7 months (range, 1–29 months).

Results

The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of cytological diagnosis by FNA biopsy for detection of liver malignancy were 91.5%, 100.0%, 100.00%, 59.1% and 92.4% respectively. All patients with AFP  400 μg/L were associated with malignancy. Of 1154 patients with AFP < 400 μg/L who were finally proved PLC, 945 were detected by FNA alone. Major complications included bleeding in 11 cases (5 of them died later), occurred mainly in hepatocellular carcinoma with superficial location, large tumors and severe cirrhosis, and implantation metastases in 5 cases, which were recognized as a subcutaneous nodule at the previous biopsy site. Implantation metastases were treated with resection or radiotherapy.

Conclusion

FNA biopsy is valuable for the diagnosis of PLC. However, complications of post-biopsy hemorrhage should not be ignored, as such bleeding may be fatal. Implantation seems to have little effect on the prognosis.

Introduction

Percutaneous fine needle aspiration (FNA) biopsy for the diagnosis of primary liver cancer (PLC) has recently been actively debated due to the progress of imaging techniques and the risk of malignant seeding after the procedure. During the last decade, advances in imaging techniques have yielded a sensitivity ranging from 89 to 96% in the diagnosis of liver cancer.1, 2 Compared with ultrasound-guided fine-needle (US-FNA) biopsy, imaging methods can eliminate the risk of tumor seeding in the biopsy-needle track and be less limited by invasiveness. However, we should not ignore the risk of false-positive resulted from imaging techniques. In a recent study, 4 of 160 patients (2.5%) underwent unnecessary surgery when their benign lesions were erroneously diagnosed as hepatocellular carcinoma (HCC) by imaging techniques.2 On the other hand, literature suggests that the specificity of FNA for the diagnosis of liver masses is almost 100%, although the sensitivity of FNA ranged from 83.3% to 97.5%.3, 4 The major complications, including hemorrhage and malignant seeding, after FNA biopsies were considered rare.5, 6, 7 However, some resent studies showed implantation metastases can precede other recurrences and shorten the patients’ overall survival.8

China has the highest mortality rate for liver cancer because of the high prevalence of the Hepatitis B virus.9, 10 Recent studies have showed that the incidence of PLC in the US and UK has increased substantially over the last two decades.11, 12 In this study, we will further characterize the usefulness, major complications of US-FNA, such as bleeding and implantation metastases, the influence of this procedure on treatment outcome and patients’ prognosis in this specified population.

Section snippets

Patient characteristics

From June 1985 to May 2005, 3113 patients presented with suspected PLC were treated at Cancer Hospital, Fudan University, Shanghai, China. One hundred two patients were excluded due to loss of follow-up. The remaining 3011 patients, including 2579 men and 432 women, were retrospective reviewed. Patient ages ranged from 10 to 98 years old, with a mean age of 50.1. The sizes of the tumors were ≤3.0 cm in 223 cases, 3.1–5.0 cm in 298 cases, 5.1–8.0 cm in 1119 cases, 8.1–10.0 cm in 747 cases, ≥10.1 cm in

Cases failed for FNA

Of the 3011 patients, 483 cases failed to have biopsies with various reasons. The major reasons were bleeding tendency defined as prothrombase time prolongation >5 s or platelet count <50,000 per ml) which can not be corrected, and poor tumor location, such as near the diaphragm or too close to the surface. Other reasons were shown in Table 1.

Diagnostic outcome

An average number of 2.1 passes were performed per case (range, 1–4 passes). Positive diagnosis of malignancy was achieved in 2061 cases. Cytology results

Operating characteristics of FNA for the diagnosis of liver malignancy

The sensitivities of FNA for detecting malignancy in some recent large research series have ranged from 83.3% to 97.5%, with specificities approaching or achieving 100%.3, 4 The sensitivity and specificity FNA in our study were 91.5% and 100.0% respectively, which compares well with previous studies. However the NPV was only 59.1%, which is lower than those of the other reports.3, 4 This low NPV may partly be explained by the small number of benign patients. Other reasons may result from

Conclusion

Based on this large series study, we conclude that US-FNA biopsy should be valuable for assessing potential liver malignancy and is accurate in the diagnosis of PLC. The risk of bleeding should not be ignored, as it is sometimes fatal, especially in large HCC coexisting superficial location and/or severe cirrhosis. The prognosis does not seem to be influenced by the occurrence of implantation metastases.

Conflict of interest

The authors have no conflict of interest to disclose.

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